The American Psychological Association (2005) states that evidence-based practice involves the integration of the best of existing research with clinical expertise and the reality of the patient’s needs and wishes. Practical and ethical concerns may limit the availability of SCI research evidence.
Difficulties inherent in conducting intervention studies are numerous (King & Kennedy 1999). The SCI population can be heterogeneous. Most sites do not have access to a large number of patients and obtaining treatment and appropriate control groups requires the participation of multiple sites. Also, ethical concerns over providing the best possible care to all SCI patients are obvious, so that withholding aspects of treatment in order to establish control conditions is no longer acceptable (e.g. Kahan et al. 2006). To date, research strategies have frequently used self-report screening measures (e.g. Beck Depression Inventory, Zung Depression Inventory, Patient Health Questionnaire-9, Center for Epidemiological Studies – Depression Scale; Older Adult Health and Mood Questionnaire; Depression, Anxiety and Distress Scale), and while they offer many benefits (e.g. low cost, quick, easy to complete), they require further evaluation to support a diagnosis of depression).
Typical SCI interventions to encourage post-SCI adjustment are often multi-faceted; thereby posing difficulties in identifying which combination of components can offer optimal care for any particular patient. Further, psychosocial interventions cannot be independent of other aspects of care (e.g. medical, rehabilitation). Wait-list control conditions do not address personal contact, attention and perceived support available in intervention conditions. In addition, many pre-morbid psychological and historical influences are very difficult to determine.
As the nature of SCI studies make it more difficult to limit certain biases, the validity and generalizability of the findings is less clear. Despite these challenges, researchers have made invaluable clinical contributions using smaller groups, non-randomized control groups, or controls chosen from historical data. However, in summarizing the limited research currently available, Elliott & Kennedy (2004) suggested “we have many untested assumptions regarding the available treatments for depression among persons with SCI” and have questioned whether the current “glaring lack of intervention data” reflects a lack of interest on the part of consumers, researchers and funding agencies with regard to various interventions for treatment of depression in those with SCI. Kahan et al. (2006) stressed that treatment of depression in people aging with a disability is “far from being developed,” noting a “massive dearth” of research of any kind for individuals with disabilities.
Three studies examined the effects of interventions aimed towards psychological impairment post SCI. In a systematic review, Elliot & Kennedy (2004) evaluated the effectiveness of depression treatments post SCI through a systematic narrative review of the results. The study found psychological interventions, pharmacological therapy and functional electrical stimulation had moderate to high level of evidence in improving depressive symptoms post SCI. Dorstyn et al. (2010) and Mehta et al. (2011) examined the effectiveness of cognitive behavioural therapy (CBT) on a range of psychosocial issues faced by individuals with SCI. Both studies found small to large effects of CBT on depressive and anxiety symptoms. Dorstyn et al. (2010) also found moderate to large effect sizes in the improvement of quality of life post CBT treatment in individuals with SCI.